HIV-associated mortality in the era of antiretroviral therapy scale-up – Nairobi, Kenya, 2015

Abstract

BackgroundDeclines in HIV prevalence and increases in antiretroviral treatment coverage have been documented in Kenya, but population-level mortality associated with HIV has not been directly measured. In urban areas where a majority of deaths pass through mortuaries, mortuary-based studies have the potential to contribute to our understanding of excess mortality among HIV-infected persons. We used results from a cross-sectional mortuary-based HIV surveillance study to estimate the association between HIV and mortality for Nairobi, the capital city of Kenya.Methods and findingsHIV seropositivity in cadavers measured at the two largest mortuaries in Nairobi was used to estimate HIV prevalence in adult deaths. Model-based estimates of the HIV-infected and uninfected population for Nairobi were used to calculate a standardized mortality ratio and population-attributable fraction for mortality among the infected versus uninfected population. Monte Carlo simulation was used to assess sensitivity to epidemiological assumptions. When standardized to the age and sex distribution of expected deaths, the estimated HIV positivity among adult deaths aged 15 years and above in Nairobi was 20.9% (95% CI 17.7–24.6%). The standardized mortality ratio of deaths among HIV-infected versus uninfected adults was 4.35 (95% CI 3.67–5.15), while the risk difference was 0.016 (95% CI 0.013–0.019). The HIV population attributable mortality fraction was 0.161 (95% CI 0.131–0.190). Sensitivity analyses demonstrated robustness of results.ConclusionsAlthough 73.6% of adult PLHIV receive antiretrovirals in Nairobi, their risk of death is four-fold greater than in the uninfected, while 16.1% of all adult deaths in the city can be attributed to HIV infection. In order to further reduce HIV-associated mortality, high-burden countries may need to reach very high levels of diagnosis, treatment coverage, retention in care, and viral suppression.

Tuberculosis burden on AIDS in Brazil: A study using linked databases

“…The greater vulnerability of this group should draw the attention of healthcare professionals, regarding the inclusion and retention in healthcare services of PLHIV [ 9 ]. A study in Kenya has shown a 4-fold risk of death in PLHIV when compared to non-infected individuals, despite a 73.6% ART coverage [ 23 ]. In this study, 71% of reported PLHIV between 2006 and 2014 had started ART, with a significant tendency to increase the proportion of PLHIV receiving ART in the period.…”

Evaluation of an HIV-Related Mortuary Surveillance System — Nairobi, Kenya, Two Sites, 2015

“…The surveillance system found higher overall estimated HIV positivity than the Spectrum model ( 28 ). Female cadavers had higher positivity rates than male cadavers, whereas the Spectrum model predicts higher postmortem HIV positivity among men than women (because of the lower estimated coverage of ART among men than women) (Table 2).…”

“…In 2015, an HIV-related mortuary surveillance system was piloted in Nairobi to determine HIV positivity among cadavers, annual cause-specific mortality rates, and annual HIV-specific mortality rates ( 27 , 28 ). Sample size calculations were performed to determine the number of specimens required to measure HIV-related deaths with prevalence as low as 5% of all deaths and the approximate duration of data collection.…”

“…Findings from the surveillance system have been published elsewhere ( 27 , 28 ). In summary, 807 cadavers of persons aged ≥15 years (age range: 15–105 years; median age: 40 years) were brought to the two mortuaries during the 33-day period.…”

Understanding men, mood, and avoidable deaths from AIDS in Western Kenya

“…Yet, there is compelling evidence that maintaining the rates of diagnosis, treatment and, crucially, suppression of viral load required to keep HIV a manageable, non-transmittable condition remains challenging. Analysis of mortuary-based HIV surveillance data in Nairobi shows that although 73.6% of adults living with HIV are on treatment, which should be leading to a palpable decrease in mortality, their risk of death is still more than four times higher than those uninfected (Young et al 2017). This is somewhat unexpected given that ART has been shown to dramatically increase life-expectancy in lower-income countries (Nsanzimana et al 2015).…”